Wednesday, April 17, 2013

Day 17/18- Placental Abruption

I'm irritable.

Maybe it's the heat. Maybe it's exhaustion. Or even more so, a combination- the physical toll of working like a mule in the Haitian heat, and the emotional tax that is entwined in the work that is birth, covered in blood and sweat and tears, literally- and then often returning to do it again for nightshift with very little sleep. Maybe it's because this is the 3rd week of essentially being a siamese twin- never being very far from my husband- living, breathing, working, sleeping, everything, never far from one another, and the stresses that come with that (No, The Amazing Race is simply not for us. We would, in fact, claw each other's eyeballs out). Maybe it's going on 3 days of living off of brownies because my stomach has reached it's limit and cannot (CANNOT!) handle more rice and beans and goat meat. Compacting all of the above, I think my irritable demeanor is also attributed to the fact that after working in the Haitian hospital for nearly 3 weeks, I feel like we've seen so much and seen what works and also all that does not make sense. Seeing things take place that have no rhyme or reason is just simply irritating.

Yesterday was the second day in a row that I have had a handful of students. Tuesday I had 2 midwifery students and two nursing students. Honestly, from the get go I was a bit irked. The nursing students have nothing to do with the Midwives for Haiti midwifery training. I am not here to teach nurses. I am here to help train midwives. I should have questioned it, but I didn't. The labor and delivery unit consists of 4 bays divided by plastic shower curtains, with one of the bays having two beds, making a total of 5 beds. The musky, sweaty, putrid box of a room is filled with cockroaches, flies, and mosquitos. Women have sheets under their bodies to absorb the bodily fluids associated with birth, and each woman usually brings a bucket to void in. Once the sheet holds it's max, everything drips to the floor, flies swarm. It's not uncommon for a mom to be laying there with flies on her bloody perineum. Picture these conditions- dirty and cramped- and add midwives. Then add midwifery students. Now add a handful of nursing students. It is ridiculous. It adds to the chaos of the environment, does not create a mother-friendly care environment, and it takes away from the good of this midwifery program.

Yesterday the preceptor tells me that she wants the nursing student to do a vaginal exam on my laboring mom. OK...this is the nursing student who cannot even get an accurate blood pressure or respiration. She has no business sticking her fingers into my patient's vagina. (Yes, I think I'm a bit bitter...) So I ask the preceptor, “Has she ever checked a cervix before?” “No,” is the answer. “Ok...has she been practicing with a dilation chart or a model?” “No.” I shook my head and shrugged my shoulders but said nothing more.

So this nursing student checks my mom and of course she has NO idea what she's feeling and what she's doing. And in the meantime, the MIDWIFERY students are standing around watching. THEY could be doing this. They SHOULD be doing this and learning from this.

Afterward, the preceptor tells me that she wants me to help the nursing student with the delivery. Looking back, I wish I would have said something. But I didn't because I did not want to create tension. There I was helping this nursing student catch a baby- who just minutes before had done her very first vaginal exam and who was not even competent enough to take accurate vitals. I may have had smoke coming out of my nostrils. It's not the preceptor's fault, it was what she was told to do by the higher-ups in the hospital.

After delivery and some skin to skin time, the baby is taken to the back counter to be weighed, measured, and examined. I have learned by observing the midwives and students that really, there is no such thing as a newborn examination, if only in textbooks. Their newborn exam consists of weighing baby, measuring baby, erythromycin in the eyes, vitamin K shot in the leg, and dressing baby in a full get-up.

After mom is stable I walk back to find a fully dressed baby on the dirty chipped countertop. Two students are standing next to the counter. Only 15 minutes or so has passed since delivery. There is NO WAY that a newborn exam has been done. I ask, “Have you done a full head to toe assessment of baby?” They look at me, hesitate, and like stuttering John's try to say yes. Almost immediately they start to undress baby so they can actually do the newborn assessment that they know they bypassed altogether.

I am angered. This isn't just a problem with the students, it is also with the midwives. I look at them and ask a simply question- “If you did not do a full assessment of this baby, who would do it?” I already knew the answer. “Would it be done in postpartum?” They acknowledged that the answer is no.

What if there was an abnormality? Would you find it if you did not look?” No.

I ended by saying, “We do not only have one patient. We have two- mom and baby...And by being a part of this birth and taking the baby to be assessed, you are accepting responsibility for this patient.” We then went on to do a full newborn exam together.

It's amusing, the contradictions of myself.

I knew what to expect with Haiti. Yet I knew nothing. I understand Haiti's problems. But I don't know the half of it. I know anything is fair game in the realm of birth here, and to expect anything and everything- but yet I continue to be surprised. And then, after the initial jolt has worn off and the adrenaline recedes, I find myself surprised that I'm surprised.

The shoulda coulda wouldas can debilitate your mind. Rehashing, rethinking, recreating the events and wondering what you could have or should have differently... It's not good, but yet for me, the process is needed. It helps me to understand and to learn from my mistakes. Life can be a series of mistakes or decisions with not ideal outcomes...but in midwifery, some of these are just not acceptable. And my mistakes can ultimately mean the loss of a mother or her baby. And so I sit here and I do the "shoulda coulda woulda.”

We had a seemingly normal woman in labor, with the typical Haitian history of gestational hypertension and possible preeclampsia. Lack of testing and a sketchy chart always makse it like putting together a 5,000 piece rather than sit for hours trying to put together the whole picture, often times we must resort to putting together the focal point of the picture.
During our nightshift there are 3 moms in labor, all in transition simultaneously. The 3 women walk the outside corridor and in and out of the unit, each harmoniously moaning, singing, praying, chanting. It is a form of music to listen to these three women. I try to lay down in the storage closet in between listening to heart tones and the harmony is getting louder and louder. 2 of them are multips and I am having visions of a baby being born onto the cement in the corridor, with the cat-rats for an audience. I get up to be prepared. The two moms come back in, one is beginning to bear down, the other is close behind. I slap on some gloves.

The Haitian midwife (who happens to be a male midwife) is using my doppler to listen to heart tones, but between the position of baby, a lot of amniotic fluid, and the doppler battery dying, the heart beat is very faint sounding. He puts it up to his ear to listen. He can hear it, but I can't. He accepts what he hears.

Mom bears down in a big push and POP, her bag of water EXPLODES, drenching Glen who is standing 4 feet away, in clear fluid. His pants are soaked down into his underwear. We laugh. He leaves to go find a change of clothes. I ask the midwife to listen to heart tones. 128 bpm.

At one point I listen myself and baby is in the 80's. I listen again and baby was at 120. I give the doppler back to him. Baby is on the perineum now. I don't like that I can't hear heart tones and I verbalize this to Glen, who has now returned in dry scrubs. Glen asks me if I want him to get the portable ultrasound to see the heartbeat. I say something I will later regret. “No, it's ok. The midwife is listening, I was just saying I don't like that I can't hear it very well.” I don't like not hearing the clippity clop of the galloping horse, that I am sure any midwife understands. That very sentence will forever hang on my conscience. What if the heart tones were low and he wasn't hearing them, wasn't saying something? I could have expedited the delivery. I don't know if it would have made a difference with the ultimate outcome, but still...I should have done it differently. Always, always listen to your instincts.

Baby's head comes out and there is an eruption of dark, bloody fluid that goes everywhere. My hands and arms are covered in her blood. I bring baby up. Baby looks lifeless and blue. We can tell that it was an abruption. We clamp and cut immediately and I whisk baby to the back, leaving the male midwife to care for mom. I know Glen and I are the only ones that can resuscitate. The baby is not breathing, heart rate is about 40. Glen bags, I do chest compressions. There is blood everywhere. Glen stops bagging for a few seconds to suction with the delee. We continue and send our translator Gladias down to the pediatric unit to get peds. In the middle of chest compressions I look up and see the Haitian midwife standing there watching. I tell the translator to tell him he needs to take care of mom. Is she bleeding?! He cannot just leave her!

I do 4 rounds of chest compressions and baby's heart begins pounding...130 bpm. Glen continues to bag the limp, baby that has the tone of a ragdoll. Once we know baby's heart is continuing to beat, we wrap the baby in a towel and walk as quickly as we can to peds, Glen carrying the baby in his arms. We enter the room, bloody, sweaty messes, say nothing, find the nearest bed, and assess baby again. Glen keeps bagging. I listen. Chest compressions are needed again. Covered in the mother's blood and dripping sweat, we work harder than we ever have to not give up on this baby until we know we have done all we could. 1-2-3-BREATHE, 1-2-3-BREATHE, 1-2-3, BREATHE...

The baby needs to be intubated but no one can find a tube small enough for a baby. We need to go to the OR. People are trying to arrange for us to take baby to the OR, walking back and forth to see if they will “accept us.” No on is running. They are walking as if on a Sunday stroll. I will never be able to get past this cultural difference. It drives me bonkers.

We finally get approved to take baby to the OR to be intubated and when we get there, the OR tech at the door blocks our way in and yells at us in Creole. He is saying, “No, you cannot go in. This is a sterile environment, you need shoe covers on!” This baby has gone 2 minutes now without being bagged...the walk from peds to the OR is not a short one. We are yelling that this baby needs help, there is no time for that. Gladias is trying his best to keep up with the translation. The man is adamant. There is a stretcher in the hallway and we rush to it to put baby on so we can continue bagging so that baby is not left without oxygen. The man is yelling at us, probably because we are using the stretcher. I lose my cool. My professionalism goes out the window, and I yell in disgust, “THIS is why babies die in Haiti!” Gladias looks away, hesitating to translate what I've just said. I yell at Gladias, “Gladias, TELL HIM WHAT I JUST SAID! THIS is why babies die in Haiti!”

I am referring to the lack of understanding, the lack of urgency, the lack of action. I'm referring to so much with that sentence.

The man grabs a pair of shoe covers and puts them on Glen's feet. Glen tries to grab the baby and enter the OR and the man blocks him again. He needs a head cover. Dear God.

We get in the OR and as soon as Glen lays the baby down, she begins to breathe on her own. We can hardly believe it. An oral airway is placed, and another woman is trying to start an IV for us. After several attempts, she looks to me to ask if I could try. Oh no. I've never in my life even seen an IV on a baby started. I can't. I shake my head no. Next time...I will know how...

After 10 tries, she gets the IV placed. We are left to our own devices. Everyone goes back to wherever they came from and it is just Glen and I left with this baby. We hang D5. It's the only thing we can find. It dawns on us that we know nothing about the infusion rate for a baby. I have internmittent cell service and I try to send a text message to the first person I can think of who can help us- Jenn. I am swearing at my phone because the message won't send. On the 3rd time it goes through. At what rate do we give D5 to a baby, I ask? She responds immediately. Is the baby term, how much does the baby weigh, what's the baby's blood sugar? She says we should ideally give D10. We don't have D10. In between texts I am rummaging through the OR. I find a vial that says it is Glucose 50. Can we add this to the bag? Jenn says yes. She calls more people, for more help. How can we combine this Glucose 50 to a liter of D5 to make it more equivalent to D10? There is math involved in this and my brain is shot.

Somehow we muddle through it and do it.
D50 just happened to be laying around

While I am figuring this out, the baby begins to shake. At first we think it's because she's cold, but then we realize that she is seizing. We don't know what to do. Glen and I are alone and we have never done this before. Gladias goes to find someone from peds and he finds the ward completely empty of staff. No doctors, no nurses, just patients. We get a hold of the pediatric resident from Ireland, who is who we have come to call when we panic. She arrives in 10 minutes. She finds valium and together, along with a dosing book, we figure out the dosage for baby. We are guessing 3 kilos for her weight.
Giving the first dose of Valium
After this, there is nothing left to do for her. Nothing left at our disposal. She continues to breathe on her own. We take her back to the pediatric unit, I take a video of the room so that I can always remember. There is one last thing to do before we leave...speak to this baby girl's mother.
We walk into the postpartum unit, lined with beds. Her bed is the last one against the back wall. I sit down beside her as she lays and say, “As of right now, your baby is alive...her heart is beating and she is breathing but she isn't stable. We had to resuscitate her for a long time and now she is having seizures. She might not survive.”

The mother looked away and nodded, saying nothing, showing nothing, acting as if she were dismissing me. I asked if she had any questions I could answer...she hardly looked at me and just said no. There were no words needed.

Today the baby is still alive and still breathing on her own. She isn't conscious or responsive though, so the overall prognosis doesn't seem very good. I guess the next few days will tell.

And that...that's really all there is to say...
The ridiculousness of my outfit and expression on my face says it all.


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